Provider Demographics
NPI:1578796678
Name:NEW MILLENNIUM MEDICAL GROUP INC
Entity Type:Organization
Organization Name:NEW MILLENNIUM MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VADIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MYSAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-455-2638
Mailing Address - Street 1:3901 HOUMA BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2930
Mailing Address - Country:US
Mailing Address - Phone:504-455-2638
Mailing Address - Fax:504-455-2639
Practice Address - Street 1:3901 HOUMA BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2930
Practice Address - Country:US
Practice Address - Phone:504-455-2638
Practice Address - Fax:504-455-2639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-24
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty